Abstract:

Background

Extended Care Paramedic (ECP) practice is aimed at managing more patients at home or in the community under a delegated scope of practice applying pre-determined clinical guidelines. These clinical guidelines have been carefully developed to mitigate the increased risk associated with treating more patients in the community. This study aimed to evaluate the compliance of the ECPs in applying the clinical guidelines for lower back pain and syncope and to analyse the risk associated with non-compliance.

Methods:

Cases of syncope or lower back pain attended by ECPs were reviewed for compliance in a two stage evaluation. Based upon the documented clinical record written by the ECP, the compliance with the clinical guideline was determined. In cases where the guideline was not followed, two independent experts assessed the potential risk of harm for a patient utilising the Ministry of Health clinical incident risk scoring system.

Results:

There were 23 lower back pain and 25 syncope cases collected between April 2011 and Feb 2012 that were assessed. In 16 (64%) of the syncope cases the patient was managed in the community, although in 7 (44%) of these the case documentation did not demonstrate guideline compliance. The most commonly missed components of the guideline were headache, recent head injury and valvular heart disease.

In 17 (74%) of the lower back pain cases the patient was managed in the community, however in 13 (76%) of these cases the case documentation did not demonstrate guideline compliance. The most commonly missed components of the guideline were weight loss and the presence of osteoporosis.

The clinical risk associated with non-compliance was assessed differently by the two experts. One expert rated 3 (43%) of the syncope cases and 9 (69%) of the lower back pain cases as being a potential sentinel risk of harm to a patient, while the second rated 1 (14%) of the syncope cases and 2 (15%) of the lower back pain cases as a potential sentinel risk.

Conclusion

This study raises significant concerns regarding documentation of guideline compliance in cases where ECPs are choosing to manage patients in the community. It is not clear whether this reflects a failure in clinical care, or a failure in the documentation of the care provided. In either case, the risk to the patient, the ambulance service and the paramedic associated with the failure in documentation is considerable. In a significant proportion of these cases the risk associated with the missing documentation was classified as sentinel, although the variance in risk classification was considerable. The discrepancy associated with the risk assessment observed demonstrates the difficulty in evaluating risk purely on the basis of documentation of cases. The level of non-compliance appears to be different for the two clinical conditions studied. Quality improvement initiatives will be required to ensure that the ECP clinical evaluation of patients and the corresponding documentation are more compliant with the current operating guidelines.